CurrentBlue Cross Blue Shield - NevadaPolicy N/A

Authorization for Release of Protected Health Information (PHI)

This document is a member authorization form that governs release of PHI from a provider to Anthem Blue Cross and Blue Shield (and affiliates/agents); it applies to members (patients) whose information is being requested for disclosure.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyAuthorization for Release of Protected Health Information (PHI)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete member identification exactly as it appears on the member ID card and verify matching fields before accepting the authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multiplemember identifying fields requested on form

checkbox listtypes of information selectable

1 yeardefault expiration

excludedpsychotherapy notes

Authorization Processing Criteria

Authorization processing criteria

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyAuthorization for Release of Protected Health Information (PHI)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete member identification exactly as it appears on the member ID card and verify matching fields before accepting the authorization.

SourceLink

On This Page

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Member identification fields must be completed exactly as they appear on the member Identification (ID) Card (e.g., name, Group ID, Individual ID number, date of birth, address, daytime telephone).

Verify fields match member record before accepting the form.

Part A must identify the provider or person authorized to disclose the member's information (e.g., provider name and relationship to the individual).

Part B must designate Anthem Blue Cross and Blue Shield (and its affiliates/agents) as the recipient of the information.

Member must indicate the scope of PHI to be disclosed by selecting either all information or one or more limited categories. Sensitive categories (e.g., abortion; abuse; alcohol/substance abuse; genetic testing; HIV/AIDS; maternity; mental health; sexually transmitted or other communicable diseases) require the member to explicitly check the applicable boxes to authorize release.

If psychotherapy notes are requested, do not accept this form for those notes; a separate authorization is required.

Member must specify the purpose of the disclosure (either 'at my request' or another stated purpose in Part D).

Expiration: the authorization expires at the earliest of (a) the date the member's coverage ends (if disclosure requested by the insurance company), (b) one year from the signature date, or (c) a specific date/event/condition within the one-year timeframe if filled in by the member.

Voluntary nature and revocation: the authorization is voluntary; the member may revoke the authorization at any time by providing written notice to the person listed in Part A. Revocation does not affect disclosures made prior to receipt of the written revocation.

Legal representative: if the form is signed by a designated legal representative or guardian, documentation of authority (e.g., health care power of attorney, court order) must be attached to the form.

Validate and retain supporting legal documentation with the authorization.

Member is entitled to a copy of the signed authorization.

Delivery/routing: completed authorizations should be returned to Anthem Blue Cross and Blue Shield (address and routing per form instructions).

Route incoming authorizations to the appropriate Quality/processing address indicated on the form.

Form Completion, Scope, and Validity

Documentation Required

Form completion and authorized discloser

Complete the form exactly as the member information appears on the member ID card. Enter member name, ID number, group number, date of birth, address, and telephone with area code precisely as shown on the card. In Part A, enter the Name of Provider (for example, physician or hospital) as the person or entity authorized to disclose the member's information and specify relationship to the individual. In Part B, the company authorized to receive information is Anthem Blue Cross and Blue Shield and its affiliates and agents (as named on the form). Ensure the form is completed in its entirety and include as much information as possible; if assistance is needed, call the number on the back of the member ID card.

Enter member identifying information exactly as shown on the member ID card (full name, middle initial, Individual ID Number, Group ID Number, date of birth, address, daytime telephone).
In Part A: provide the Name of Provider (physician, hospital, etc.) and relationship to the individual.
In Part B: the authorized recipient is Anthem Blue Cross and Blue Shield and its affiliates and agents.

Note

Scope of PHI to be disclosed

Member must select the scope of PHI to be disclosed. Options include authorizing release of all information (health and financial) or limiting disclosure to specific categories. Limited categories available include appeals; benefits & coverage; billing; claims & payment; diagnosis & procedure; eligibility & enrollment; financial; medical records (excludes psychotherapy notes); physician & hospital; pre-certification & pre-authorization; referral; treatment; dental; vision; pharmacy; behavioral health. The form also permits authorization to release sensitive information (must be specifically checked) such as abortion, abuse, alcohol/substance abuse, genetic testing, HIV/AIDS, maternity, mental health, sexually transmitted or other communicable diseases, or other specified items. The form allows free-text for additional specifics.

Choice between: All my information (health and financial) OR limited information (check applicable categories).
Limited categories include appeals; benefits & coverage; billing; claims & payment; diagnosis & procedure; eligibility & enrollment; financial; medical records (excludes psychotherapy notes); physician & hospital; pre-certification & pre-authorization; referral; treatment; dental; vision; pharmacy; behavioral health.
Sensitive information requires explicit selection (e.g., abortion; abuse; alcohol/substance abuse; genetic testing; HIV/AIDS; maternity; mental health; sexually transmitted diseases).
There is an option to specify other categories in free-text.

Note

Voluntary nature, revocation, and expiration

Authorization is voluntary and may be revoked in writing at any time by giving written notice to the person listed in Part A. Revocation will not affect actions taken prior to receipt of the written revocation. By signing, the individual acknowledges they have read and understand the authorization and that treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing. The default expiration is the earliest of: the date coverage ends (if disclosure requested by the insurance company), one year from the signature date, or another date/event/condition specified within the one-year timeframe. This form cannot be used to authorize disclosure of psychotherapy notes; a separate form is required for psychotherapy notes. Individuals are entitled to a copy of the authorization.

Authorization is voluntary and may be revoked in writing; revocation does not affect prior disclosures.
Default expiration: earliest of coverage end date (when applicable), one year from signature, or a specified date/event within one year.
Psychotherapy notes are excluded — separate authorization required.
Individual is entitled to a copy of the signed authorization.

Special Categories and Legal Representatives

Psychotherapy notes (special handling)

DefinitionPsychotherapy notes are excluded from this authorization form and cannot be authorized here; a separate form is required to authorize their use or disclosure.

Implication for processingIf psychotherapy notes are requested, do not accept this form; request the member complete the designated separate psychotherapy-notes authorization form.

Member notificationThe form includes a clear note informing the signer that psychotherapy notes require a separate authorization form.

Designated legal representative / guardian (documentation required)

Required documentationA copy of a Health Care Power of Attorney, a court order, or other documentation establishing custody or legal authority must be attached when signed by a legal representative/guardian.

Form fieldsLegal representative must print full name, state legal relationship to individual, sign and date the form.

Processing actionValidate and retain the supporting legal documentation with the authorization form before accepting or processing disclosures.